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STATE OF CALIFORMA <br /> STATE WATER RESOURCES CONTROL BOARD aro <br /> UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM B <br /> COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. n <br /> MARK ONLY I NEW PERMIT 3 RENEWAL PERMIT - 5 CHANGE OF iNFORMATICN — T PERMANEN <br /> ONE ITEM - 2 INTERIM PERMIT a AMENDED PERMIT 6 TEMPORARY TANK CLOSURE 8 TANK REMOVED /J'1,4 <br /> I � <br /> CBA OR FACILITY NAME WHERE TANK IS INSTALLED: �--� <br /> I. TANK DESCRIPTION CCMP_ETE ALL ITEMS- SPECIFY IF UNKNOWN <br /> A. OWNER'S TANK I.D.a B. MANUFACTURED By: <br /> C. DATE INSTALLEDIMC/DAYIYEAR) D. TANK CAPACITY IN GALLONS: n <br /> ILTANKC ENTS IFA-11SMARKED.COMPLETEITEMC. <br /> A t MOTOR VEHICLE FUEL `—'. a CIL B. i C. _I la REGULAR 1 3 DIESEL - 6 AVIATAN GAS'UNLEADED a ^uASAHOL <br /> L... 2 PETROLEUM V w EMPTY I! I PRODUCT =, PREMIUM LEADED <br /> � _I T METHANOL <br /> ,ice UNLEADED 5 .'c FUEL <br /> -1 3 CHEMICAL PRODUCT � 95 UNKNOWN I (1 2 WASTE i� 2 LEADED <br /> u 199 OTHER ;DESCRIBE IN ITEM 0. 9EL0'N) <br /> 0. IF(A.:)IB NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.1: <br /> III. TANK CONSTRUC N MARK ONE ITEM ONLYIN BOXESA.B-AND O.AND ALL THAT APPLIES IN BOX O ANOE <br /> A. TYPE OF 1 DOUBLE WALL 3 SINGLE WALL WITH EXTERIOR LINER u 95 UNKNOWN <br /> SYSTEM 2 SINGLE WALL 6 SECONDARY CONTAINMENT IV c0 TANIB N OTHER <br /> 1 BARE STEEL 2 STAINLESS STEEL 3 FISERGLASS ! A STEEL CLAD 'N/FIBERGLASS REINFORCED PLASTIC <br /> 3. TANK <br /> 8 POLYVINYL CHLORIDE �'� ] ALUMINUM - 9 100'A METHANOL COMPATIBLE WIFRP <br /> MATERIAL 5 CONCRETE <br /> (Pnmary Tank) 9 BRONZE 10 GALVANIZED STEEL 95 UNKNOWN W OTHER <br /> 1 RUBBER LINED 2 ALKYD LINING =-r"3 EPDXY LINING A PHENOLIC ENING <br /> C.INTERIOR 5 GLASS LINING 8 UNLINED J 95 UNKNOWN W OTHER <br /> LINING <br /> IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ <br /> D.CORROSION I POLYETHYLENE WRAP 2 COATING IJ 3 VINYL WRAP �, a FIBERGLASS REINFORCED PLASTIC <br /> PROTECTION 5 CATHODIC PROTECTION J 91 NONE 95 UNKNOWN 99 OTHER <br /> E.SPILL AND OVERFILL SPILL CONTANMENT:NSTALUED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) <br /> IV.PIPING INFORMATION CIRCLE A IIFABOVEGROUNOOR U IF UNDERGROUND.BOTH IF APPLICABLE <br /> A. SYSTEM TYPE A U I SUCTION A 2 PRESSUPE A U 3 GRAVITY A U W OTHER <br /> B. CONSTRUCTION A U I SINGLE WALL A U 2 DOUBLE WALL A 3 LINED TRENCH A U 95 UNKNOWN A U W OTHER <br /> C. MATERIAL AND A U I BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A FIBERGLASS PIPE <br /> CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U T STEEL W/COATING A U 8 I0 METHANOL COMPATIBLE WffRP <br /> PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U W OTHER <br /> D. LEAK DETECTION I AUTOMATIC LINE LEAK DETECTOR 2 LINE TIGHTNESS TESTING 'IIONRORNG W OTHER <br /> V.TANK LEAK DETECTION <br /> ^I 1 VISUAL CHECK INVENTORY RECONCILIATION J 3 VADOZE MONITORING i- a AUTOMATIC TANK GAUGING 5 GROUND WATER MONITORING <br /> !-7 8 TANK TESTING INTERSTITIAL MONITORING 91 NONE 95 UNKNOWN - 99 OTHER <br /> VI.TANK CLOSURE INFORMATION <br /> '.ESTIMATED DATE LAST USED(MOIDAYNR) L ESTIMATEDOUANTITY OF 1 WAS TANK FILLED WITH YES = NO <br /> SUBSTANCE REMAINING GALLONSI INERTMATERIALl L— L-- <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE SEST OF MY KNOWLEDGE. IS TRUE ANO CORRECT <br /> APPLICANPS NAME DATE <br /> i <br /> IPBINTE�aSWNATURO <br /> LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW /I . <br /> COUNTY 9 JURISDICTION# FACILITY 9 TANK a V A <br /> STATE I.D.# J j ]N� 1Z�L <br /> PERMITNUMBER PERMIT APPROVED BY/DATE <br /> THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. <br /> FILE THIS FORM WITH ICAL AGENCY IMPLEMENTING THE UNCERGROUND STrIP,^9 TANK REGULATIONS <br /> /�v <br /> -ORM a ;12 911 <br />